Vol 41 # 3 September 2009 - Kma.org.kw

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KUWAIT MEDICAL JOURNAL September 2009
Original Article
Blunt and Penetrating Thoracic Trauma: Management
Strategy and Short-Term Outcome
Adel K Ayed 1,2 , Hassan Jamal-Eddine 2 , Chazian Chandrasekran 2 , Murugan Sukumar 2 , Nael Al-Sarrraf 2
1
Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait
2
Chest Diseases Hospital, Ministry of Health, Kuwait
Kuwait Medical Journal 2009; 41 (3): 226-229
ABSTRACT
Objectives: To review our experience with blunt
and penetrating chest injuries that required surgical
interventions
Design: Retrospective case series
Settings: Six general hospitals in Kuwait
Subjects: One hundred fifty nine patients who underwent
emergency surgery for thoracic trauma
Intervention: Urgent thoracic surgical procedures
(thoracotomy or sternotomy)
Main Outcome Measures: Pattern of injuries, indications
for surgery, surgical approaches, short-term morbidity
and mortality
Results: One hundred fifty-nine patients (68 with blunt
and 91 with penetrating injuries) underwent thoracotomy
or sternotomy between January 1995 and December 2006.
The mean age was 27 years (range: 2 - 70 years). The causes
of penetrating injuries were stab wounds (n = 65), gunshot
wounds (n = 19) and iatrogenic (n = 7). The causes of blunt
thoracic injuries were motor vehicle accidents (n = 63) and
fall from height (n = 5). The indications for thoracotomy
were hemorrhage (n = 115), airway disruption (n = 14),
pericardial tamponade (n = 5), clotted hemothorax (n = 8)
and diaphragmatic rupture (n = 17). Major lung resections
were performed in four patients (2.5%). The morbidity
was 10 / 159 (6%) and the mortality was 7 / 159 (4.4%).
The majority of deaths were due to adult respiratory
distress syndrome (ARDS).
Conclusion: Prompt thoracotomy can be performed with
minimal morbidity and mortality in cases of blunt and
penetrating thoracic injuries. The complex pattern of such
injuries requires a detailed assessment and management
by a thoracic surgeon.
KEY WORDS: blunt thoracic trauma, penetrating injury, sternotomy, thoracotomy
INTRODUCTION
Thoracic traumas comprise 10 - 15% of all traumas
and are the causes of death in 25% of all fatalities
due to trauma [1] . Seventy percent of thoracic traumas
are blunt and the remaining are penetrating injuries.
Despite timely and aggressive management of blunt
and penetrating thoracic trauma, patients with blunt
trauma still have a significantly higher mortality than
penetrating trauma [1-3] . The management of thoracic
injuries are often by tube thoracostomy. However, in
many patients these injuries must be treated surgically
in one of the three time periods: immediate, urgent,
or delayed thoracotomy [3-6] . In this article, we sought
to review our experience with blunt and penetrating
chest trauma that required surgical intervention.
PATIENTS AND METHODS
This is a retrospective review of all thoracic traumas
in six general hospitals in Kuwait city and surrounding
regions that required surgical intervention in the form of
thoracotomy, sternotomy or other surgical approaches
during the period from January 1995 to December 2006.
A total of 159 patients were reviewed. All these patients
initially presented to emergency departments and
following initial assessment and chest radiograph, tube
thoracostomy was performed, if indicated, according to
the standards of Advanced Trauma life Support (ATLS)
guidelines. Fiber-optic bronchoscopy was performed
when airway injuries were suspected in the presence
of persistent air leak. Computed tomography (CT) of
the chest was performed in some cases as indicated
by the individual case scenario. Patients were then
transferred to the operating room or intensive care unit
according to their hemodynamic status and a detailed
assessment was carried out by a thoracic surgeon.
Indications for urgent surgery include initial chest
tube drainage of 1000 ml or consecutive drainage of
200 ml of blood per hour for three consecutive hours;
persistence of hypovolemic shock despite aggressive
resuscitation in penetrating injuries, massive air
leak without lung expansion, evidence of bronchial
rupture on bronchoscopy, cardiac tamponade, proven
diaphragmatic rupture and endoscopic or radiographic
evidence of esophageal injury.
Address correspondence to:
Dr. Adel K. Ayed, Professor, Department of Surgery, Faculty of Medicine Kuwait University, P.O. Box: 24923, 13110, Safat, Kuwait. Tel: 965-5319475, Fax: 965-5319597,
E-mail: Adel@hsc.edu.kw